Most often, when you see a doctor or need health care services, the provider you see files a claim with your insurance company. You pay your portion and then the doctor’s office handles the rest.
However, there may be times when you need to file a health insurance claim yourself. This means you need to let your health insurance company know what services you received, where and for how much. You may need to pay your copay, coinsurance or deductible for the service at the time and then your insurance company will reimburse you for covered portions.
When and how to submit a health insurance claim
When you receive care within your plan’s network, the service provider handles the filing for you. But sometimes you may need to go outside your plan’s network or receive services from providers that don’t file with your insurance.
Out-of-network care
One of the most common reasons you would need to file your own claim is if you visit a doctor or service provider who is outside your plan’s network. Some plans provide coverage for out-of-network care, often at a higher deductible or co-insurance rate. If your insurance plan does cover out-of-network care, you’ll need to work with the doctor, lab or specialist to receive the proper documentation.
You can ask your doctor for a detailed receipt, often called a “superbill,” that lists the procedure codes for each service you received. You’ll then file the charges for each procedure code. The insurance company may pay you back for some of the costs incurred or apply those costs toward your out-of-network deductible.
Care when traveling
When you receive care outside the United States or on a cruise ship, you’ll need to submit your own health insurance claim for reimbursement. This is because most health insurance companies have specific forms to fill out for international travel. Make sure to have a detailed, itemized receipt from the health care provider that lists all services performed and the cost.
Vision care or prescription products
Some service providers for vision care, prescription drugs or durable medical equipment may be covered under your plan, but they might not file claims with your insurance. You can submit a claim with your insurance to get reimbursed for some or all costs for these products or services.
How to File an Insurance Claim Form
Oh, and you also get a giant bill because the small-town hospital is out of your network and won’t work with the insurance you have from three states away. You’re going to need to file a health insurance claim form. Here’s what you need:
1. Claim Form
Your insurance company should have a health insurance claim form on their website. This will be a special claim form specific to your health plan. They’ll probably have a way to file the claim online, which is nice. But you should also be prepared to print the claim form and mail it in. Here are some things you may need to include on the form:
- Your insurance policy number, member number or group plan number
- The name of the patient receiving medical treatment (you, your spouse, your child or anyone covered under your plan)
- Whether or not you have dual coverage or coinsurance
- The reason for the treatment (like an injury, illness or preventive care)
If you get into an accident at work and workers’ compensation covers it, you may need to fill out lots of special paperwork and go through a different insurance company than your normal health insurance company. You’ll want to talk to your Human Resources representative or consult an attorney who specializes in workers’ compensation. This is also true if you get hurt in an auto accident or because of someone else’s negligence (like if you slip and fall on a wet surface inside of a business). These claims can get really complicated, and it’s good to have someone in your corner.
2. An Itemized Bill and Receipts
This is important. You absolutely must get an itemized bill from your provider. It should detail every service your doctor provided and include things like:
- Examinations
- Lab tests like blood work or urine tests
- Radiology exams like X-rays, MRIs and CT scans
- Medications dispensed
- Surgery
- Cardiovascular tests like EKGs and echocardiograms
- Durable medical equipment like crutches or braces
In other words: If the doctor bills for it, you need to include it in the list. Each item should be on a separate line and should include the ICD-10 code (more on this below) for each procedure.
3. Copies of Everything
Make a copy of every single document you receive and put it into a file specifically marked for your claim. You’ll want to keep everything in one place so you can easily find anything you may need later. Insurance claim forms sometimes get denied or lost, and they’re subject to all kinds of shenanigans. So disputes can happen. Being able to quickly and easily refer to your paperwork is a lifesaver.
Once you have everything organized, it’s time to file the claim. Most of the time, you can do this online. But sometimes you may have to submit a claim form by mail. Contact your insurance company. They should be able to walk you through the submission process.
Additional considerations
You should rarely need to file a claim yourself, especially if you see providers within your network. It’s important to understand what’s covered under your plan and what’s not, so you know whether you need to file a health insurance claim at all.
In general, preventive care, essential health benefits, in-network care and medically necessary services are covered. Cosmetic procedures, experimental or investigational treatments as well as services not described in your benefits summary are not covered. Not all plans cover out-of-network care, so before filing a claim, check if your insurance offers this coverage.
If you have any questions about the process, call the number on the back of your health insurance card.